Case Report
Selective thrombolysis performed through meningo-ophthalmic artery in central retinal artery occlusion

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Abstract

The poor natural history of central retinal artery occlusion (CRAO) is usually not modified with conventional, conservative management techniques. Guidelines for selective intraarterial ophthalmic thrombolysis are still lacking. While many centers continue to perform this procedure with promising results, others are reluctant due to conflicting findings in recent studies. We present our experience in a 36-year-old male with CRAO. Based on the patient’s clinical presentation, we planned to perform selective intraarterial ophthalmic thrombolysis via the ophthalmic artery. When angiography demonstrated that the retina was not supplied by the ophthalmic artery, but by a meningo-ophthalmic artery branching from the internal maxillary artery, we instead administered thrombolytic agents via the meningo-ophthalmic artery. The patient’s vision recovered completely, with visual acuity and visual field examination at 30 day follow up comparable to his pre-treatment status. This case emphasizes the need for external carotid artery examination in cases of nonvisualization of the ophthalmic artery. In addition, it illustrates the successful use of the meningo-ophthalmic artery to perform selective intraarterial thrombolysis for CRAO.

Introduction

Total and subtotal central retinal artery occlusion (CRAO) presents a grim visual prognosis if managed with conventional conservative methods.1 Several open-label clinical studies using continuous infusion of thrombolytic agents have suggested that local intra-arterial fibrinolysis is efficacious in the treatment of CRAO,[1], [2] however, a recent multicenter randomized trial showed conflicting findings.3 Adequate patient selection, procedure timing and technical aspects are only a part of the ongoing debated issues on CRAO therapy. The therapeutic goal is to restore the retinal blood flow as soon as possible before permanent and extended visual damage occurs, allowing for significant visual recovery. This goal can be achieved by rapid selective infusion of fibrinolytic agents through ophthalmic artery proximal to the origin of the central retinal and ciliar arteries. We present an unusual case of CRAO that was successfully managed with ophthalmic artery fibrinolysis performed through the meningo-ophthalmic artery.

Section snippets

Case presentation

A 36-year-old-male with a history of valvular heart disease was found to have a CRAO in his left eye. He presented due to a sudden, painless, complete monocular loss of vision twelve hours before admission to the ophthalmology ward. Upon examination, the pupil responded poorly to direct light but constricted briskly when the contralateral eye was illuminated (relative afferent pupillary defect). Fundoscopy showed retinal edema, a cherry-red macular spot, and sluggish circulation through the

Discussion

Intraarterial fibrinolysis has been used primarily in the treatment of thromboembolic occlusion of the cerebral arteries, with good results.4 Early applications in the ophthalmic territory produced a high rate of recanalization of the central retinal artery, with better outcomes than achieved with conservative treatment.[5], [6] Selective fibrinolysis primarily acts by relieving of the embolic occlusion or the central retinal artery. A timely revascularization may save the retina at risk

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